Inadequacies of the medical record assessed by physician reviewers* (n=4317) and the association with the occurrence of adverse events
| Frequency (%) | OR for adverse event (95% CI) | |
| Medical record inadequate or incomplete | 20.0 | 1.5 (1.3 to 1.9)† |
| Report of past medical history and physical examination at admission inadequate or incomplete | 12.4 | 1.3 (1.0 to 1.7)† |
| Other reports not available or incomplete (eg, operation/procedure report, diagnostic imaging results, reanimation report or autopsy report) | 11.0 | 1.7 (1.3 to 2.1)† |
| Discharge letter not available | 10.7 | 1.0 (0.7 to 1.3) |
| Lack of clarity regarding decisions and changes in policy | 8.3 | 2.0 (1.5 to 2.6)† |
| Discharge summary not adequate, because*: | 7.9 | 1.9 (1.5 to 2.4)† |
| Discharged diagnose is missing | 2.8 | 1.9 (1.2 to 3.0)† |
| Prognosis is missing | 2.1 | 1.5 (0.9 to 2.7) |
| Treatment policy is missing | 3.5 | 1.7 (1.1 to 1.5)† |
| Agreement of supervisor is missing | 0.9 | 1.2 (0.5 to 2.8) |
| Notes on procedure related to adverse event inadequate | 6.9 | 3.2 (2.5 to 4.3)† |
| Lack of clarity regarding who was responsible for decisions and changes in policy | 5.8 | 2.5 (1.8 to 3.4)† |
| Lack of clarity when changes in policy were made | 5.5 | 1.7 (1.2 to 2.4)† |
| Admission reason not clearly described | 4.0 | 1.3 (0.9 to 2.0) |
| Other | 2.2 | 1.5 (0.9 to 2.6) |